toxins Sialorrhea: Anatomy, Pathophysiology and Treatment with

Toxins 2013, 5, 1010-1031; doi:10.3390/toxins5051010
OPEN ACCESS
toxins
ISSN 2072-6651
www.mdpi.com/journal/toxins
Review
Sialorrhea: Anatomy, Pathophysiology and Treatment with
Emphasis on the Role of Botulinum Toxins
Amanda Amrita Lakraj 1, Narges Moghimi 2 and Bahman Jabbari 1,*
1
2
Department of Neurology, Yale School of Medicine, 15 York Street LLCI-920 New Haven,
CT 06520, USA; E-Mail: [email protected]
Department of Neurology, Case Western Reserve University; Cleveland, OH 44106, USA;
E-Mail: [email protected]
* Author to whom correspondence should be addressed; E-Mail: [email protected];
Tel.: +1-203-737-2464; Fax: +1-203-737-1122.
Received: 1 March 2013; in revised form: 9 April 2013 / Accepted: 24 April 2013 /
Published: 21 May 2013
Abstract: Sialorrhea or excessive drooling is a major issue in children with cerebral palsy
and adults with neurodegenerative disorders. In this review, we describe the clinical
features, anatomy and physiology of sialorrhea, as well as a review of the world literature
on medical treatment using Yale University’s search engine; including but not limited to
Medline and Erasmus. Level of drug efficacy is defined according to the guidelines of
American Academy of Neurology. Current medical management is unsatisfactory. Topical
agents (scopolamine and tropicamide) and oral agents (glyccopyrolate) combined render a
level B evidence (probably effective); however, this treatment is associated with
troublesome side effects. Double-blind and placebo-controlled studies of botulinum toxin
(BoNT) provide a level A evidence for type B (two class I studies; effective and
established) and both overall and individual B level of evidence for OnabotulinumtoxinA
(A/Ona) and AbobotulinumtoxinA (A/Abo); these are probably effective. For
IncobotulinumtoxinA (A/Inco), the level of evidence is U (insufficient) due to lack of blinded
studies. Side effects are uncommon; transient and comparable between the two types of
toxin. A clinical note at the end of this review comments on fine clinical points. Administration
of BoNTs into salivary glands is currently the most effective way of treating sialorrhea.
Keywords: botulinum neurotoxins; botox; drooling; pytialis; double-blind; therapy;
topical agents; oral agents
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1. Introduction—Definition and Incidence
Sialorrhea, also known as drooling or ptyalis, is a debilitating symptom which occurs when there is
excess saliva in the mouth beyond the lip margin [1]. Drooling is common in normally developed
babies but subsides between the ages 15 to 36 months with establishment of salivary continence [1].
It is considered abnormal after age 4 [2]. Pathologic sialorrhea can be an isolated phenomenon due to
hypersalivation or occur in conjunction with several neurologic disorders such as amyotrophic lateral
sclerosis (ALS), cerebral palsy (CP), Parkinson’s disease (PD), or as a side effect of medications. In
children, the most common cause of sialorrhea is CP, which persists in 10%–38% of these individuals [3].
In adults, PD is the most common cause [4] with 70%–80% of PD patients demonstrating sialorrhea [5].
In 30%–80% of schizophrenic patients, hypersalivation when taking clozapine is manifested [6].
Regardless of the cause, drooling is problematic, leading to clinical and functional complications such
as impairment in social functioning (embarrassment and isolation), aspiration, skin breakdown, bad
odor, and infection [7].
The major salivary glands include parotid, submandibular, and sublingual glands; the largest
being the parotid gland. These glands secrete saliva which has a major role in lubrication, digestion,
immunity and maintenance of homeostasis in the human body [8]. The parotid gland is located in the
preauricular region, along the posterior surface of the mandible and is divided by the facial nerve into a
superficial lobe and a deep lobe. The submandibular gland is the second largest major salivary gland,
is located in the submandibular triangle, and lies posterolateral to the mylohyoid muscle. The
sublingual gland is the smallest of the three and lies in the anterior floor of the mouth [9]. Saliva is
produced in high volumes relative to the mass of each gland (parotid produces the most because it is
the largest) and is almost completely controlled extrinsically by the autonomic nervous system, both
sympathetic and parasympathetic divisions [8].
In the unstimulated state, 70% of saliva is secreted by submandibular and sublingual glands.
Conversely, in the stimulated state the parotids glands provide most of the saliva. The flow of saliva is
five times greater in the stimulated state than in the resting state [7]. An example of an exogenous
source causing stimulation is chewing.
Sialorrhea can be either due to increased production of saliva (idiopathic or drug-induced) or
related to failure of mechanisms that clear and remove saliva from the oral cavity. Disturbance in the
coordination of orofacial and palate—lingual musculature is one mechanism that can lead to pooling of
saliva in anterior portion of mouth. Ultimately, muscle incoordination inhibits the initiation of the
swallow reflex, thereby further disrupting the path of saliva from the mouth to the oropharynx [10].
Salivary secretion is regulated via a reflex arch which has various influences. The afferent branch
consists of chemoreceptors in taste buds and mechanoreceptors in the periodontal ligament. Afferent
innervations of cranial nerves V, VII, IX and X also play a role by carrying impulses to salivary nuclei
in the medulla oblongata [11]. Efferent influences are mainly parasympathetic via cranial nerve VII
which control the submandibular, sublingual, and other minor glands, and CN IX which influences the
parotid gland [11].
Sialorrhea occurring with neurologic illnesses is usually due to impaired swallowing as a result of
impaired neuromuscular function. Neuromucular activity of swallowing involves efficient coordination
of several structures including the oral cavity, pharynx, larynx, and esophagus [7]. These structures
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coordinate to form three phases; an oral phase which is under voluntary control, followed by the
pharyngeal and esophageal phases which are under involuntary control [12]. Spontaneous swallowing
is necessary for drool control [7]. In children with neurologic disorders, drooling appears to be an
effect of inefficient tongue and/or bulbar control, rather than increased salivary secretion [13].
2. Objective
The objective of this paper is to provide a comprehensive review of sialorrhea and its various
neurologic presentations, thus providing information on anatomy, physiology, and current treatment
methods with an emphasis on the role of botulinum neurotoxins (BoNTs). The evidence for treatment
efficacy is presented according to the guidelines of the American Academy of Neurology [14] (Table 1).
Table 1. AAN classification of evidence [14,15].
Class
I
II
III
IV
Criteria
Prospective, randomized, controlled,
outcome masked, representative
population with criteria A–E *
Prospective, matched cohort,
representative population, masked
outcome and meets A–E * OR RCT with
one criteria in A–E * lacking
Controlled trial **, representative
population, outcome independent of
patient treatment
Uncontrolled study, case series,
case report or expert opinion.
Level of
Evidence
Recommendation
A: Two or more
Class I studies
Established as effective,
ineffective, or harmful
B: At least one
Class I or two
Class II
Probably effective,
ineffective, or harmful and
recommended
C: At least
one Class II
Possibly effective, ineffective
or harmful, may be used at
discretion of clinician
U
Data inadequate or conflicting
* A = Primary outcome(s) clearly defined, B = exclusion/inclusion criteria clearly defined, C = Adequate
accounting for drop-outs and cross-over with numbers sufficiently low to have minimal potential for bias,
D = relevant baseline characteristics or appropriate statistical adjustment for differences, E = For
non-inferiority or equivalence trials claiming to prove efficacy for one or both drugs, the following are also
required: (1) The standard treatment used in the study is substantially similar to that used in previous studies
establishing efficacy of the standard treatment (e.g., for a drug, the mode of administration, dose, and dosage
adjustments are similar to those previously shown to be effective); (2) The inclusion and exclusion criteria
for patient selection and the outcomes of patients on the standard treatment are substantially equivalent to
those of previous studies establishing efficacy of the standard treatment; and (3) The interpretation of the
results of the study is based on an observed-cases analysis; ** Including well-defined natural history controls
or patients serving as their own controls.
3. Method
Information for this paper was collected by searching the Yale Medical Library Database, which
utilizes a wide range of scholarly search engines including, but not limited to, Pubmed, Erasmus, Ovid,
EBSCO and Cochrane databases. Literature was searched from the time line 1960 to present, including
literature ahead of print and articles not in English. Terms used for search included “saliva”,
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“drooling”, “sialorrhea”, “hypersalivation”, “ptyalis”, “double-blind”, “therapy”, “treatment”,
“botulinum toxin”, and “botulinum neurotoxin” in various combinations.
4. Treatments
Sialorrhea is known to be difficult to treat. Management can be conservative or more invasive.
Conservative treatments include changes in diet or habits, oral-motor exercises, intra-oral devices such
as palatal training devices, and medical treatments such as medication or botulinum toxin injections.
Behavior modification has been advocated for many decades but results are inconsistent and time
consuming [16]. More invasive treatments include surgery or radiation [17]. While surgical cases seem
to offer more permanent results, they are invasive and are not without side effects. Radiation is now
rarely applied and is typically reserved for elderly patients who are not candidates for surgery and
cannot tolerate medical therapies [18].
4.1. Oral (Table 2)
Oral therapy for sialorrhea encompasses the use of anticholinergic agents such as glycopyrrolate,
benztropine, scopalamine and tropicamide. Biperiden has also been implicated for use in the literature
but was found in one study to have an adverse effect on cognition, thus limiting its use [19].
Glycopyrrolate oral solution is the first drug treatment which was approved in the United States for
drooling in children with neurologic conditions [1]. Anticholinergic agents work by downregulating
acetylcholine and ultimately decreasing saliva secretion through the parasympathetic autonomic
nervous system [17]. Elderly patients have poor tolerance for anticholinergic agents. Glycopyrrolate
specifically has a quaternary ammonium structure and thus cannot pass the blood-brain barrier in large
amounts, ultimately decreasing the occurrence of central side effects [20]. It is effective and safe at
1 mg, three times a day. Intraoral tropicamide films provide short-term relief of sialorrhea. One study
provided evidence that 1 mg of tropicamide resulted in significant Visual Analog Scale (VAS) score
decrease and reduction in saliva volume in non-demented PD patients [21]. Antireflux medication has
also been suggested for use in drooling [22]; however, there are no double-blind studies in the
literature to offer evidence for this recommendation as per our search.
Level of Evidence
Six double-blind studies investigated the efficacy of oral agents in sialorrhea (Table 2). The
majority focused on oral anticholinergics (glycopyrrolate or benztropine). One investigated the use of
intraoral tropicamide films, and the other studied the efficacy of sublingual ipratroprium bromide.
These six studies are comprised of three class II and three class III studies, yielding an overall B level
of evidence (probably effective).
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Table 2. Treatment of sialorrhea with pharmacological oral and topical agents.
Author and
year
Agent
Associated
illness
N
Study design
Class
Outcome measured
Findings
Side effects
Minor problems (dry
mouth) eliminated by
Camp-Bruno
BZ (mean dose
et al. 1989 [23]
3.8 mg)
DD
20
DB, PBOC,
CO
III
Efficacy and incidence of side-effects at 1-week,
baseline, 2-week PBO and 2-week BZ conditions
A significant decrease in drooling
small dose adjustments.
during the BZ condition relative to
More serious cholinergic
PBO was demonstrated and
side-effects which
conservative response rates ranged up
resolved in 24–48 h
to 65%–70%
required discontinuations
of the drug in three
patients.
Even at low doses, 20%
Mier
et al. 2000 [24]
DB, PBOC,
GLYC
DD
39
CO, Dose-
III
ranging
Parent and investigator evaluation of change in
GLYC in doses of 0.10 mg/kg per dose
sialorrhea and adverse effects
is effective at controlling sialorrhea
of children may exhibit
adverse effects severe
enough to require drug
discontinuation.
Sublingual
Ipratropium
Thomsen
Bromide Spray
et al. 2007 [25]
(1–2 sprays up
Randomized,
PD
17
DB, PBOC,
Ipratopium bromide spray had no
II
Objective measure of weight of saliva production
CO
to 4 times a
significant effect on weight of saliva
produced.
No significant adverse
side effects
day)
Severity of drooling was quantified using a
Mato
Topical
Handicapped
et al. 2010 [26]
Scopolamine
*
30
prospective,
modified Thomas-Stonell and Greenberg visual
randomized,
scale simplified into three grades: 1 = dry;
DB, PBOC,
CO
II
2 = mild/moderate; 3 = severe/fulsome. The
frequency of drooling was estimated using the
number of bibs used each day.
Significant drooling reduction
(p < 0.005) in the scopolamine group in
the 1 and 2 week controls (69% and
80% respectively ≤ grade 3). The mean
number of bibs/day decreased during
the scopolamine phase from 6/day at
baseline to 3/day at the 2 week control.
4 patients (13.3%)
dropped out because of
scopolamine side effects
and minor adverse
reactions were observed
in three other patients
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Table 2. Cont.
Author and
year
Agent
Associated
illness
N
Study design
Class
Outcome measured
Findings
Side effects
Mean sialorrhea score improved from
4-week,
Arbrouw
GLYC 1 mg 3
et al. 2010 [20]
times daily
PD
23
randomized,
DB, PBOC,
II
CO
Sialorrhea was scored on a daily basis by the
4.6 (1.7) with PBO to 3.8 (1.6) with
No significant differences
patients or a caregiver with a sialorrhea scoring
GLYC (p = 0.011). 9 patients (39.1%)
in adverse events between
scale ranging from 1 (no sialorrhea) to 9 (profuse
with GLYC had a clinically relevant
GLYC and PBO
improvement of at least 30% vs. 1
treatment.
sialorrhea).
patient (4.3%) with PBO (p = 0.021).
At 1 week, both drugs improved CIS
compared with baseline (biperiden:
12-week,
Liang
GLYC and
et al. 2010 [19]
Biperiden
CI
13
randomized,
DB, CO,
III
Sialorrhea and global cognitive function were
assessed by using DRS and MMSE respectively
fixed-dose
p = 0.005; GLYC: p = 0.002). DRS
2 adverse events were
score was lower than baseline in 4
reported by the patients
weeks with biperiden (p = 0.003) and
during both treatment
also with GLYC at 4 weeks
phases. 1 patient
(p = 0.002). MMSE scores with either
complained of
drug did not differ from baseline at one
constipation, and the other
week or 4 weeks (p = 0.437,
complained of inner
p = 0.76). Patients treated with
unrest
biperiden had significantly reduced
MMSE scores after 1 week (p = 0.049).
DB,
Lloret
Intra-oral
et. al. 2011
Tropicamide
[21]
films
1 mg of tropicamide resulted in
randomized,
PD
19
PBOC,
two-phased,
Latin-square
CO study
significant VAS score decrease and
II
VAS and saliva amount by cotton rolls.
reduction in saliva volume (27%, 33%,
and 20% respective for 0.3,
No adverse events were
reported
1 and 3 mg) when compared to PBO
Double Blind (DB), Placebo Controlled (PBOC), Cross over (CO), Glycopyrrolate (GLYC), Number of subjects (N), Visual Analogue Scale (VAS), Drooling Rating Scale (DRS), Mini
Mental Status Exam (MMSE), Parkinson’s Disease (PD), Cerebral Palsy (CP), Developmentally Disabled (DD), Clozapine-Induced (CI). *11 cerebral palsy, 5 epilepsy, 4 autism, 3 Dpwns
syndrome and 3 cases of rare disorders
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4.2. Topical (Table 2)
One double-blind study of 30 patients handicapped by debilitating illnesses (CP, epilepsy, autism,
Down syndrome and rare disorders) is described in the literature using transdermal scopolamine.
Moderate or severe mental retardation was present in 80% of patients. Severity of drooling was
quantified using a modified Thomas-Stonell and Greenberg visual scale and frequency of drooling was
monitored by number of bibs used each day. A significant drooling reduction was noted (p < 0.05);
however, four patients dropped out due to side effects and minor adverse events were noted in three
others. It was concluded that though scopolamine can be useful to control drooling in severely disabled
patients, it is not free from adverse effects, thus requiring careful patient selection [26].
Level of Evidence
This class II study justifies a C level of evidence (possibly effective)
4.3. Surgical
Various surgical procedures have been suggested for treatment of drooling. These procedures all
encompass an alteration in the anatomy of the salivary glands and include salivary gland excision,
denervation of the salivary glands, and transposition or ligation of the salivary ducts [27]. These
procedures are reserved for severe cases and of course are not without their side effects.
5. Botulinum Toxin Treatment (Table 3)
The effect of Botulinum toxin (BoNT) on drooling was first noted in PD patients [28]. BoNT, a
potent neurotoxin blocks the release of acetylcholine and a number of other neurotransmitters from
synaptic vesicles [28]; in this case post-ganglionic parasympathetic fibers are cholinergic. It has been
reported to be effective in the treatment of sialorrhea through various open label trials, retrospective
studies, case studies and controlled clinical trials. Currently, three type A and one type B toxin are
approved for use in US. These include OnabotulinumtoxinA (A/Ona), AbobotulinumtoxinA (A/Abo),
IncobotulinumtoxinA (A/Inco), and RimabotulinumtoxinB (B/Rima).
Below we provide the evidence for the use of BoNT in sialorrhea divided into three categories:
BotulinumtoxinA (BoNT-A) vs. placebo (Table 3), BotulinumtoxinB (BoNT-B) vs. placebo (Table 4)
and comparator studies looking at BoNT-A vs. BoNT-B or BoNT-A vs. topical (transdermal) agents
(Table 5). BoNT injections are given in the parotid and submandibular glands, as they are the greatest
contributors to salivary production (Figure 1 [29]). The facial nerve, which is important in facial
expression, is very close to the parotid gland; caution must be taken when injecting to avoid this nerve
(Figure 2 [30]). Although local anesthesia may be used to reduce the pain of injection, out of all the
studies reported in this review, only two used it. In one, authors used generalized anesthesia before
injection in the pediatric population [31]. In the other, local anesthesia with Emla cream was used in
five of the patients [32].
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Table 3. Double blind studies for botulinum toxin A vs. placebo.
Author/year
Assoc.
illness
Lipp et al.
12 ALS, 12 PD,
2003 [28]
4 MSA, 4 CBD
N
32
Class
II
Agent/dose
A/Abo 18.75, 37.5,
or 75 MU
Glands
Primary
injected
outcome
Weight of dental rolls every
B/L PG
4 weeks during a 24-week
period
Treatment efficacy and safety
were assessed at baseline,
Mancini
2003 [33]
14 PD, 6 MSA
20
II
450 U A/Abo
B/L PG and B/L
1 week and 3 months after
SMG
A/Abo injections using clinical
scales (DS and DF) and side
effect surveillance
Result
Side effects
Significant decrease of sialorrhea during
the study period measured by dental rolls
when compared with PBO group p < 0.05
None reported
only in the 75 U group
After treatment, the average secretion of
saliva in the A/Abo group was significantly
lower than in the PBO group as appraised by
None
clinical measurements (p = 0.005);
no treatment difference at 3 months
DSFS, VAS-FD and SD,
UPDRS-ADL item scores for
Lagalla et al.
2006 [34]
drooling and swallowing at
PD
32
II
A/Ona50 U per PG,
B/L PG
baseline and 1 month after
treatment. Saliva reduction
(weight of dental rolls). GIS was
Subjects treated with A/Ona experienced a
reduction in both drooling frequency and
familial and social disability, as well as in
saliva production (p < 0.0001)
Mild transient
swallowing
difficulty in 1 pt
also applied
Significant difference in DSFS at 2, 4, 6, 8,
12 week post injection, saliva weight at 6,
Lin et al.
2008 [16]
CP
13
III
Ona/A 2U/kg
C/L PG
body weight
and SMG
DSFS, saliva weight, and DQ
12 week after injection, and DQ 2, 6, 8,
Not stated
10 week after injection all significant at
in text
p < 0.05. Saliva weight significant to longest
follow up of 22 weeks.
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Table 3. Cont.
Author/year
Assoc. illness
N
Class
Agent/dose
Glands
injected
Primary outcome
Result
Side effects
Scores of the median frequency
Minor and transient
(p = 0.034) and severity (p = 0.026)
increase in drooling
of drooling were reduced in the
after Injection in
treatment group.
2 pts *
DF and DS were performed at
the time of injection, at 1 month,
Alrefai et al.
2009 [35]
CP
24
III
100 U A/Abo in the
and at baseline prior to the
first visit and 140 U
second injection. A second set
at the second visit
4 months later
B/L PG and
SMG
regardless of effect
of injections of either 140 U of
A/Abo or PBO was given
4 months later, and the same
rating scales were used using
Fisher’s Exact Test
Pei-Hsuan
Wu et al.
CP
2011 [36]
20
I
A/Ona body weight
B/L PG and
titrated
SMG
Subjective drooling scales,
Decrease in salivary flow rate was
salivary flow rate, and oral
significantly higher in the A/Ona group
health (salivary compositions
at the 1-month (p = 0.037) and 3-month
and cariogenic bacterial counts)
(p = 0.041) follow up compared
at 1 and 3 months
to control
No reported adverse
effects
* 2 patients experienced a mild/transient increase in drooling which the authors proposed can be explained by either improper placement of the injection or to local leakage of BoNT into surrounding muscles
resulting in weakness of mouth closure.
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Table 4. BTX-A vs. PBO studies: Technical information.
Author/year
Lipp et al.
2003 [28]
Method used to locate
injection site
Anatomic landmarks
Mancini
2003 [33]
Ultrasound
Lagalla et al.
2006 [34]
Anatomic landmarks
Lin et al.
2008 [16]
Alrefai et al.
2009 [35]
Pei-Hsuan Wu
et al. 2011 [36]
Method of injection
30-gauge, 25-mm needle were used to inject each
parotid gland. (one in gland mass (0.3 mL), one
above masseter 0.2 mL)
Through a 26-gauge syringe, 0.65 mL of solution in
each parotid gland and 0.35 mL of solution in each
submandibular gland.
27-gauge needle penetrating to adepth of 1–1.5 cm into the
preauricular portion of parotid gland, behind the angle of the
ascending mandibular ramus,and then into the inferoposterior
portion of the gland, lying just before the mastoid process.
Number of sites injected
Use of
anesthesia/type
2 per parotid
Not stated
Not clear, but assumed
1 injection per gland on
both sides
Not stated, however
patients complained of
painful injections
3 per parotid
Not states
Ultrasound
Not stated in paper
Not stated in paper
Not stated
Anatomic landmarks
Each side was injected with a 10 mm (30 G) needle into the
paotid gland with 50 U.
2 per parotid
Not used
Ultrasound
30-gauge needle to the bilateral parotid and submandibular
glands with concentration of 10 U/0.1 mL.
4 (1 injection in both
parotids and
submandibular glands)
Not stated
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Table 5. Comparator studies.
Author/year
Assoc.
illness
N
Class
Agent/dose
Glands
injected
Primary outcome
Result
Side effects
Drooling decreased with both scopolamine and
A/Ona injection; however greatest reductions
Jongerius
et al. 2004
A/Ona by weight
CP
45
III
[32]
vs. transdermal
scopolamine
B/L
DQ, Teacher Drooling Scale
SMG
(TDS) and VAS
were achieved 2 to 8 weeks after A/Ona injection.
61.5% of patients responded to BoNT injections.
Statistical significance for DQ was stated at
(p < 0.05). DQ had a response rate of 53% for
71% had moderate to severe side
effects for scopolamine. Only
minimal and incidental side
effects were reported for BoNT.
scopolamine and 48.7% for A/Ona
Wilken
et al. 2008
CP or NDD
30
III
[31]
Guibaldi
et al. 2011
[40]
ALS (15)
and PD (12)
27
III
100 /kg of B/Rima
B/L PG
or 80 MU of
and
A/Ona
SMG
250 U A/Abo or
2,500 U B/Rima
Parent questionnaire and
TDS
Four weeks after the first injection 29 patients
Intermittent problems with
responded with a reduction of TDS score to
swallowing due to viscous
1 or 2 rated in the parent’ s questionnaire.
saliva (5), unilateral parotitis (1).
Magnitude of change in
B/Rima showed improvement in subjective and
B/L PG
saliva production
objective measured with a shorter latency for
and
determined by weighing five
improvement onset when compared to A/Abo
SMG
cotton rolls after retaining
(p = 0.002). Mean benefit of duration was
for 5 minutes in the mouth.
75 days for A/Abo and 93 days for B/Rima.
Change in saliva thickness
CP—Cerebral Palsy, NDD—Neurodegenerative Disorder, ALS—Amyotrophic Lateral Sclerosis, PD—Parkinson’s Disease, DQ—Drooling quotient, TDS—Teacher Drooling Score,
BoNT—Botulinum Neurotoxin, A/Ona—OnabotulinumtoxinA, B/Rima—RimabotulinumtoxinB, VAS—Visual Analog Scale, A/Abo—ABobotulinumtoxinA, B/L—Bilateral, PG—Parotid Gland,
SMG—Submandibular gland.
Toxins 2013, 5
Figure 1. Locations for Parotid gland injections. This figure depicts the way in which
Lagalla et al. [29] inject into the parotid gland (the black x’s). Many of thestudies have
used the same approach, injecting in only 2 sites on the parotid gland. At our institution,
we inject into nine different sites and have modified the figure to portray this by the
blue dots. Modified with permission from Springer [29].
Figure 2. Facial Nerve location in relation to parotid gland. It is important to note the
anatomical location of the facial nerve in relation to the parotid gland in order to avoid
injury to this functionally important nerve during injection.
1021
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6. Commentary on Studies
We have determined the level of evidence for BoNT efficacy based on reviewed studies
(Tables 3, 4, 6). The data on children is limited. In adults, the level of evidence for BoNT-A (A/Ona,
A/Abo, and A/Inco) overall, when combining both placebo-controlled and comparator studies, is Level
B. Both A/Ona and A/Abo have level B evidence individually, as well. A/Ona evidence is based on
five studies (1 class I, 1 class II, and 3 class III). A/Abo evidence is based on four studies: three class II
and 1 class III study. For A/Inco the level is U (insufficient evidence) due to the lack of blinded
studies. Level of evidence for botulinum toxin B (B/Rima) is A (established efficacy), based on two
class I, three class II and one class III.
As implied from this data, there is now strong evidence that both A and B types of BoNTs are
effective in treatment of sialorrhea and both have a low profile of side effects. Despite the strong level
of evidence collectively, the cited studies are not without limitations. One such limitation is that of
outcome measures. There is significant heterogeneity of outcome measures among the studies. In some
studies outcome measures were poorly defined. Some studies measured only qualitative clinical scales
(drooling and activity of daily living) [31–33,35,37–39], others measured quantitative data such as
saliva flow through weight of dental rolls [28,40] and yet others measured both [16,29,34,36].
Outcome measures were also evaluated at different time points (for most studies at four weeks).
Another limitation is variability of injection technique. A recent review paper stated that factors
affecting diffusion and spread of BoNT include dose, concentration and volume of injectate, number of
injections, injection site, rate of injection, gauge of needle, and distance of needle tip from the
neuromuscular junction [42]. The tables with technical information (Tables 4, 7, 8) depict this
variability regarding doses, sites of injection and use of ultrasound. The optimal dose and dilution
concentration (1:1, 2:1, 4:1) still deserve further investigation.
In regards to duration of effect, one study suggested a length of duration up to six months [40],
whereas most others reported three months.
For location of injection, the studies presented focus on injections into the salivary glands (parotid
and submandibular). Only one study discussed experience with direct injection into sublingual glands
under the tongue with BoNT-B which lead to occurrence of dysphagia in two of four patients without
any improvement in sialorrhea, thus discouraging this approach [37].
A lack of correlation between reduction in salivary secretion and improvement in drooling has been
observed in some studies and is probably related to the fact that factors influencing the severity of
drooling and reduction of saliva secretion are variable [51].
Side effects in general were few and mild. Among them, transient dysphagia was the most
worrisome, resolving in two weeks and affecting a small number of patients.
One comparator study suggested better efficacy for type B toxin. Another indicated more
side effects with type B. These need to be further investigated with weighing the efficacy vs.
side effects.
Toxins 2013, 5
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Table 6. Double-blind studies for botulinum toxin B vs. placebo.
Author/year
Ondo
2004 [37]
Assoc.
illness
PD
N
16
Class
II
Agent/dose
B/Rima 2500 U
(1000 U in each PG)
Glands injected
PG and SMG
Primary outcome
Result
Side effects
UPDRS, Drooling Rating Scale,
Improvement on the VAS (p <0.001), GIC (p < 0.005),
Dry mouth (3),
DSFS, VAS, GIS at baseline and
Drooling Rating Scale (p < 0.05), and DFSS (p < 0.001).
worsened gait (2),
one month, drooling and
There was no change in UPDRS, head posture, or
diarrhea (1), neck pain
dysphagia questionnaires
Dysphagia Scale
(1) in B/Rima group
GIC of 82% at 2 weeks compared to 38% of those who
Jackson et al.
2009 [38]
B/Rima 2500 U
ALS
20
I
(500 U in PG, 750 U
in SMG)
B/L PG
GIC by the subject 8 weeks after
and SMG
the injection.
received PBO (p < 0.05). This significant effect was
sustained at 4 weeks. At 12 weeks, 50% of patients who
No adverse side effects
received B/Rima continued to report improvement
compared to 14% of those who received PBO.
DSFS, VAS-FD and VAS-SD,
Lagalla
2009 [29]
PD
36
II
4000 U B/Rima
PG
One month after injections, B/Rima group showed
UPDRS-ADL scores for
improvement in almost all subjective outcomes.
drooling and swallowing at
Two-way analysis of variance gave a significant time ×
Transient dysphagia
baseline and one month after
treatment effect, F-value being 52.5 (p < 0.0001) for
worsening which
treatment. Objective saliva
DS-FS, 23.2 (p < 0.0001) for VAS-FD, 29 (p < 0.0001)
resolved in 2 weeks in
B/Rima group (3)
reduction (saliva production
for VAS-SD, and 28.9 (p < 0.0001) for UPDRS-ADL
over five minutes by weighing
drooling item score, with benefits in B/Rima group
dental rolls), GIS
lasting 19.2 +/− 6.3 weeks
At 4 weeks postinjection, Drooling Frequency and
Chinnap-ongse
et al.
2012 [39]
ALS
and PD
B/Rima 1500, 2500 or
54
I
3500 U for PG and
250 U for the SMG
PG and SMG
Severity Scale scores significantly improved vs. PBO in
GI-related events more
Safety/tolerability, as assessed
a dose-related manner (p < 0.0001 and p < 0.0001
frequently in the active
by adverse events
respectively). Unstimulated salivary flow rates
groups (dry mouth
significantly decreased in all active
most common)
groups vs. PBO (p ≤ 0.0009).
A/Ona: Onabotulinumtoxin A (Botox); A/Inco: incobotulinumtoxinA (Xeomin); A/Abo: abobotulinumtoxinA (Dysport); B/Rima: RimabotulinumtoxinB (Myobloc), Drooling Severity (DS), Drooling Frequency (DF),
Unified Parkinsonsons Disease Rating Scale (UPDRS), Activities of Daily Living (ADL), Visual Analog Scale (VAS), Visuo-analogic ratings of familial distress (VAS-FD) and social distress (VAS-SD), Global
Impression Score (GIS), Drooling Frequency and Severity Scale (DFSS), Global Impression of Change (GIC), Drooling Quotient (DQ), Placebo (PBO), Bilateral (B/L), Contralateral (C/L), Parotid gland (PG),
Submandibular gland (SMG), Amyotrophic Lateral Sclerosis (ALS), Parkinson Disease (PD), Multiple System Atrophy (MSA), Corticobasal Degeneration (CBD), Cerebral Palsy (CP), Number of Subjects (N).
Toxins 2013, 5
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Table 7. Double blind studies for botulinum toxin B vs. Placebo-technical information.
Method used to locate injection
site
Method of injection
Number of sites injected
Use of
anesthesia/type
Ondo et al.
2004 [37]
Anatomical landmarks
All injection sites were localized with anatomic markers
and injected with a 29-gauge tuberculin syringe at a depth
of 0.5 inch. Two vertically placed locations just dorsal to
the palpated masseter muscle (parotid gland) were
injected as well as one location just anterior and medial to
the genu of the mandible (submandibular gland).
2 places in both parotids
and 1 site in both
submandibular glands.
Not stated
Jackson et al.
2009 [38]
EMG—For the parotid, absence of
motor unit potential was used to
confirm placement. For the
submandibular when insertional
motor unit activity was observed
(indicating myohyoid/
hyoglossus/digastric), the needle
was withdrawn slightly until
muscle activity was absent deep in
the submandibular triangle.
Each parotid gland was injected at two sites with 0.1 cc of
study medication (total of 500 U/gland) directing the
needle toward the tail of the parotid, between the
sternocleidomastoid muscle and the angle of the
mandible. Each submandibular gland was injected at two
sites with 0.15 cc of study medication (total of
750 U/gland), placing the needle percutaneously in the
submandibular triangle.
Each parotid gland was
injected at two sites, Each
submandibular gland was
injected at two sites
Not stated.
Lagalla et al.
2009 [29]
Anatomical landmarks
0.8 mL of drug into each pre-auricular portion of the
parotid gland. The injections were performed using a
1 mL syringe with 27-gauge needle penetrating to a depth
of 1–1.5 cm into two sites, behind the angle of the
ascending mandibular ramus and into the infero-posterior
portion of the gland, just before the mastoid process.
2 sites in each parotid
Not stated
Chinnapongse
et al.
2012 [39]
Anatomical landmarks
Not described
Not described
Not stated
Author/year
Toxins 2013, 5
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Table 8. Technical information for Comparator Studies.
Author/year
Jongerius
et al. 2004 [32]
Wilken
et al. 2008 [31]
Guibaldi
et al. 2011 [40]
Method used to locate injection site
Ultrasound
Method of injection
Number of sites injected
Injected bilaterally in the submandibular glands using
3 per submandibular gland
a 25-G needle * after general anesthesia
Injected into parotid (one in front of the isthmus and the other
Ultrasound
one below) and submandibular using 27G needle *after local
anesthesia with 20% Emla in 5 pts.
Ultrasound
3 site per side: 2 in the parotid and
one in the submandibular gland
parotid gland (two sites per gland) and each
Not clearly stated
submandibular gland (one site per gland)
Table 9. Summary of reviews discussing use of BoNT for sialorrhea.
Author & year
Focus of review
Conclusions
Reddihough
et al. 2010 [41]
Adult and children with
different etiologies
Study suggests established evidence (Level A) for
both BoNT-A and BoNT-B
Lim
et al. 2010 [42]
Discusses the use of botulinum toxin
in neurologic practice
Reviews the available treatments for
sialorrhea (pharmacologic
and non-pharmacologic)
Botulinum toxin in the management
of MS
Cochrane review on individuals with
MND/ ALS: BoNT, radiotherapy.
An update on the efficacy of
treatments for non-motor symptoms
of PD based on EBM methodology
using RCTs.
Suggests level B evidence for BoNTs in sialorrhea
(probably effective)
BoNT when injected into the parotid gland may
improve quality of life up to 4 months, injection into
salivary ducts not recommended.
BoNTs should be used with caution in MS since no
blinded or controlled studies exist.
Suggested use of BoNT-B for treatment of
sialorrhea in clinical practice due to better efficacy.
BoNTs A and B: established efficacy in sialorrhea.
Glyccopyrolate: efficiency beyond one week
is not established. Ipratropium bromide spray:
insufficient data
Dand
et al. 2010 [43]
Habek
et al. 2010 [44]
Young
et al. 2011 [45]
Seppi
et al. 2011 [46]
Comments
Conclusions based on randomized controlled trials, systematic
reviews, AAN criteria but for some studies class rating does
not accord with AAN rating (example Alrefai et al. is rated
class I; rated class III by AAN search members).
Conclusion based solely on two class II studies, and it is
unclear which class II studies were used
No assessment of level of evidence was cited
There are no controlled studies to date on the application in
MS patients with sialorrhea.
For BoNT efficacy only double-blind study
(Jakson et al.2009) was cited and many open studies.
Different used for assessment of efficacy than AAN
criteria are referenced.
Toxins 2013, 5
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Table 9. Cont.
Author & year
Squires
et al. 2012 [47]
Rodwell
et al. 2012 [48]
Intiso
et al. 2012 [49]
Walshe
et al. 2012 [50]
Focus of review
Adults with different
neurological conditions
Systematic Review of Efficacy of
BoNT in children with cerebral palsy
Review focused of BoNT use in
neurohabilitation for sialorrhea
(ALS, PD and CP).
Interventions to treat drooling in
children with CP
Conclusions
Pharmacologic intervention is effective but short
lived. Evidence is strongest for BoNTs
Data from 6 RCT suggest efficacy of BoNTs in
sialorrhea. More data on adverse effects are needed.
BoNTs and B are both effective in reducing
drooling. Type B: more effective, shorter latency;
more side effects. Duration of effect: comparable.
Unable to reach conclusion on efficacy/safety of
BoNTs or pharmaceutical interventions in CP.
Comments
Conclusions/recommendations for clinical practice brief
without applying evidence based assessment criteria.
Review is limited to children with cerebral palsy.
Does not describe levels of evidence and is not limited to
highest level of evidence studies
Looks only at the pediatric population
BoNT—Botulinum toxin, MS—Multiple Sclerosis, ALS—Amyotrophic Lateral Sclerosis, PD—Parkinson’s Disease, EBM—Evidence-Based Medicine, RCT—Randomized Controlled Trial,
AAN—American Academy of Neurology, MND—Motor Neuron Disease, CP—Cerebral Palsy.
Toxins 2013, 5
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A recent meta-analysis study (2012) [22], which reviewed all randomized placebo-controlled trials
encompassing 181 patients, concluded that botulinum toxin decreases the severity of drooling in
patients with sialorrhea with statistical significance in both adult and pediatric populations. It was
further concluded that both BoNT-A and BoNT-B produce similar effects [22]. Furthermore, BoNT-A
toxin doses greater than 50 U produced stronger effects. Increased saliva thickness (3.9%), dysphagia
(3.3%), xerostomia (dry mouth) (3.3%), and pneumonia (2.2%) are noted as common side effects.
BoNT treatment holds many advantages over older proposed methods of therapy: limited side effect
profile, convenience, low risk of aspiration and its minimally invasive nature, are just a few [22].
Limitations of using BoNT injections include expense and need for repeated sedation, which is more
problematic in pediatric population.
7. Conclusions
As of now, level of evidence and low rate of adverse side effects indicate that administration of
BoNT-A and BoNT-B into salivary glands is the most effective way of treating sialorrhea (levels B
and A evidence, respectively). Injections are simple and when executed by experienced hands, side
effects are uncommon and manageable. Overall, efficacy of both toxins and their side effect profiles
are comparable [49]. Special care needs to be applied when dealing with patients with ALS or those
already affected by dysphagia [49]. Oral agents are probably effective (level B) but anticholinergic
side effects limit their use particularly in the elderly population. Topical agents are possibly effective
(one class II study level C) but effects are short lived. In the pediatric population, only three
double-blind studies exist which are class III, hence rendering a U level of evidence (insufficient) [50].
Several reviews on sialorrhea and management have been published recently [25,41–44,46–50]
(Table 9). The majority of these reviews have a limited scope, either focusing on a single disease
category (multiple sclerosis, Parkinson’s disease, amyotrophic lateral sclerosis, cerebral palsy) or
specific population (pediatric or adult). Furthermore, several of these studies lack level of evidence or,
as in one case, have used a different system of efficacy assessment [46]. The report of Reddihough
et al. is a review on the subject from a European team using the evidence criteria of the American
Academy of Neurology (AAN). Due to differences in interpretation of AAN criteria, the evidence
depicted in this report gives a level of evidence which is higher than levels depicted in our paper, as
evidenced by the high number of class I studies in their report compared to ours.
Our review covers the published literature on prospective and controlled studies (with placebo arm
or comparator) until December 2012. It covers BoNTs, as well as oral and topical agents. The level of
evidence is provided with adherence to the AAN guidelines.
8. Technical Note from Senior Author
Defining the correct technical approach for botulinum toxin injections in sialorrhea is still an
evolving issue. Many studies which have not used ultrasound for guiding injections report good results
using anatomical landmarks. Particularly, the optimum number of injections into parotid glands is still
a subject of debate. Since parotid gland anatomy is variable (sometimes extending anteriorly over
masseter or posteriorly and inferiorly below the angle of the jaw), we at Yale practice using a larger
number of subcutaneous injections and have been doing so for the past decade. Injections are done in a
Toxins 2013, 5
1028
grid-like pattern using three rows, with three sites injected in each row (Figure 1). The top row is at the
level of tragus. This technique provided satisfaction in 90% of patients treated over the past
10 years, encompassing more than two hundred patients. Improvement is measured using
patient global impression of change (PGIC). Our standard dosage is 30–40 units of A/Ona
(about 0.05 cc per site) and 1250–1500 of B/Rima (about 0.03 cc per site) per parotid in adults. If
parotid injection alone does not work, then a combined parotid and submandibular injection is done the
next time. The submandibular injection is done at two points under the maxillary arch with a total of
30 units of A/Ona or 1000 units of B/Rima per side. We use anatomical guidelines for injections.
Injections are carried out subcutaneously with a 30-gauge, half-inch needle.
Conflicts of Interest
None of the authors have anything to disclose and authors declare no conflicts of interest. No
financial support was accepted for this paper.
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